BETH ISRAEL DEACONESS PHYSICIAN ORGANIZATION, LLC

Transcription

1 BETH ISRAEL DEACONESS PHYSICIAN ORGANIZATION, LLC CONTRACTED HEALTH PLANS CLAIMS FILING LIMIT GRID Health Plan Aetna Beech Street Blue Cross Blue Shield of Massachusetts ChoiceCare CIGNA HealthCare Consolidated Health Plans Fallon Community Health Plan First Health Great-West (formerly One Health Plan) HMC-PPO/Northeast Healthcare (recently acquired by MultiPlan) Harvard Pilgrim Health Care Harvard University Group Health Program Healthcare VALUE Management Integrated Health Plan Medicaid MassHealth Medicare MultiPlan Neighborhood Health Plan Network Health Pinnacle Health Private Health Care Systems TRICARE/Health Net Federal Services Tufts Health Plan UniCare Commonwealth Indemnity United Healthcare United Student Insurance Claims Filing Limit 60 days 90 days 90 days 90 days 90 days 90 days 60 days 90 days 120 days 180 days 180 days 60 days 18 months 90 days will accept up to one year with waiver 60 days will accept up to 18 months 60 days 90 days 90 days 60 days 60 days 1 year 90 days 2 years 90 days 90 days will accept up to one year 3/1/2005

2 BETH ISRAEL DEACONESS PHYSICIAN ORGANIZATION, LLC CONTRACTED HEALTH PLANS BILLING GRID (A B C D E F G H I J K L M N O P Q R S T U V W X Y Z) Health Plan Billing Address For Claim Issues Call: Electronic Payor ID Aetna HMO Plans: Aetna Health Inc. P.O. Box 1125 Blue Bell, PA Non HMO Plans: Aetna Health Inc. P.O. Box El Paso, TX Beech Street Blue Cross Blue Shield of Massachusetts Chickering (Student Plan) Chickering Claims Admin. P.O. Box Boston, MA Send claims to address on back of member's ID card Paper claims: Blue Cross and Blue Shield of MA Data Capture PO BOX 9196 North Quincy, MA Paper claims: Blue Cross and Blue Shield of MA PO BOX 9197 Quincy, MA Refer to number on back of member's ID card N/A ChoiceCare Send claims to address on back of member s ID card Refer to number on back of member's ID card CIGNA Healthcare Consolidated Health Plans Send to address on back of card except for those noted below CIGNA OF MA- Healthsource products only: PO Box 2083 Concord, NH CIGNA OF NH PO Box 2041 Concord, NH Consolidated Health Plans 195 Stafford Street Springfield, MA CIGNA Product Healthsource Product: plan.com ENVOY N/A 3/1/2005

3 Health Plan Billing Address For Claim Issues Call: Electronic Payor ID Fallon Community Health Care Fallon Community Health Plan PO Box Worcester, MA First Health Send claims to address on back of member's card Refer to number on back of member s ID card N/A Great-West Healthcare (formerly One Health Plan) Send claims to address on back of member's ID card. There is now a default address if claim address is unknown: Great-West Healthcare PO Box Fort Scott, KS Refer to number on back of member's ID card For electronic claims submission questions, call: ext HMC-PPO/Northeast Healthcare (recently acquired by MultiPlan) Send claims to address on back of member's ID card Refer to number on back of member's ID card Harvard Pilgrim Health Care First time submission- Commercial HPHC PO Box Quincy, MA ext ENVOY: First time submission- First Seniority HPHC PO Box Quincy, MA Claims resubmission HPHC PO Box Quincy, MA Motor Vehicle Accidents: HPHC PO Box Quincy, MA Coordination of Benefits: HPHC PO Box Quincy, MA Worker's Comp HPHC PO Box Quincy, MA Healthcare VALUE Management Hospital claims: Healthcare VALUE Management 100 River Ridge Drive Norwood, MA N/A Integrated Health Plan Send claims to address on back of member's ID card Refer to number on back of member's ID card N/A 3/1/2005

4 Health Plan Billing Address For Claim Issues Call: Electronic Payor ID Medicaid-MassHealth Division of Medical Assistance PO Box 9101 Somerville, MA DMA7384 Medicare NHIC P.O. Box 1212 Hingham, MA MultiPlan Send claims to address on back of member's ID card Refer to number on back of member's ID card N/A Neighborhood Health Plan Neighborhood Health Plans Attention: Claims 253 Summer Street Boston, MA ext Network Health Network Health Claims Department PO Box Cambridge, MA Pinnacle Health Send claims to address on back of member's ID card Refer to number on back of member's ID card Private Health Care Systems Send claims to address on back of member's ID card Refer to number on back of member's ID card N/A TRICARE/Health Net Federal Services TRICARE Claims: Health Net Federal Services, Inc. c/o PGBA, LLC/TRICARE P.O. Box Surfside Beach, SC TRICARE ( ) vices.com NEIC/WebMD All other clearinghouses Tufts Health Plan For appeals addresses see attachment. Initial Submission: HMO claims: Tufts Health Plan PO Box 9163 Watertown, MA Contact EDI services Susan Hoffman ext POS/EPO claims: Tufts Health Plan PO Box 9171 Watertown, MA PPO claims: Tufts Health Plan PPO PO Box 9185 Rockland, MA POS : Brighton Marine PO Box 9203 Watertown, MA Secure Horizons: Secure Horizons PO Box 9183 Watertown, MA /1/2005

5 Health Plan Billing Address For Claim Issues Call: Electronic Payor ID UniCare Commonwealth Indemnity Commonwealth Service Center Claims Department PO Box 9016 Andover, MA United Healthcare Send claims to address on back of member's ID card Refer to number on back of member's ID card m United Student Insurance Claims Department Student PO Box Dallas, TX NEIC /1/2005

6 BETH ISRAEL DEACONESS PHYSICIAN ORGANIZATION, LLC CONTRACTED HEALTH PLANS APPEAL REQUIREMENTS Health Plan Claim Filing Limit Appeals Filing Limit Paper Claim Electronic Claims Aetna 90 days Aetna will review claims up to 2 years old as long as there is proof of timely submission. Phone Process for HMO claims: attempt to resolve claims issues by first calling the Provider Relations Phone Unit at (some reps can resolve claims under $500). For Non-HMO claims: call the member services phone # on back of ID card. Written appeals process: Copy of claim, written explanation of concern/nature of appeal, amount expected to receive and all supporting documentation. Submit written appeals to: Please refer to Aetna s At-a-Glance Reference Guide for claims addresses. Phone Process for HMO claims: attempt to resolve claims issues by first calling the Provider Relations Phone Unit at (some reps can resolve claims under $500). For Non-HMO claims: call the member services phone # on back of ID card. Written appeals process: Copy of claim, written explanation of concern/nature of appeal, amount expected to receive and transmission reports. Submit written appeals to: Please refer to Aetna s At-a-Glance Reference Guide for claims addresses. Note: Depending on the type of appeal, the following additional documentation may be required: operative notes, pathology reports, complete description of services rendered, etc. (revised 3/05)

7 Health Plan Claim Filing Limit Appeals Filing Limit Paper Claim Electronic Claims Beech Street National PPO 60 days It will vary by client. Call the number on back of card. Information will vary by client. Call the number on back of Information will vary by client. Call the number on back of Blue Cross Blue Shield of Massachusetts 90 days 180 days Non COB claims: Provider Appeal Form, completed claim and Managed Care Report form BCBSMA as proof of timely submission (see sample form and footnote below). COB claims: an EOB from the other insurance company or from Medicare that has the processed date that is within one year of the BCBSMA receipt date. The EOB must have a processed date within one year for both indemnity and managed care claims. Regardless of how the claims is submitted, if Medicare or another insurance denies a managed care claims because BCBSMA is the primary insurer, you have 90 days from the other insurer s denial date to submit the claim. Special consideration can be given if you have a BCBSMA member who failed to provide you with accurate health insurance information at the time of the service, causing a delay in your ability to submit claims in an appropriate time period. In this case, submit a paper claim form, a Provider Appeal form and a detailed chronological summary of the action steps you took to obtain the correct insurance information. Provide a description of how the member identified themselves at the time of the service and written verification that you referenced the member s file for prior insurance information. HealthWire: Rpt-04 File Detail Summary Report, Accepted Batch with Claim Detail Report, Claim error report, BCBSMA Monthly Managed Care Claims Received Report. HealthWire Direct: WebMD Accepted Batch with Claim Detail Report, Claim Error Report and BCBSMA Monthly Managed Care Claims Received Report. InfoDial: The claim number (which can be accessed within hours after submission via the Claims Status Transaction, BCBSMA Monthly Managed Care Claims Received Report. Submit these claims to: BCBSMA Provider Services PO Box 5000 Rockland, MA ChoiceCare 90 days 365 days Information will vary by client. Call the number on back of Information will vary by client. Call the number on back of Note: Depending on the type of appeal, the following additional documentation may be required: operative notes, pathology reports, complete description of services rendered, etc. (revised 3/05)

8 Health Plan Claim Filing Limit Appeals Filing Limit Paper Claim Electronic Claims CIGNA Healthcare 60 days 180 from the date of initial denial. Consolidated Health Plans Fallon Community Health Plan 90 days Within 60 days from the date of initial denial. 90 days 90 days from the original denial or payment date First Health 60 days It will vary by client. Call the number on back of card. Copy of claim, written explanation and pertinent documentation (follow up calls, patient account screen shots) and CIGNA s Provider Payment Appeal Form. Copy of claim, written explanation and pertinent documentation (patient account screen shots) Attached supporting documentation. (Screen shot of patient accounting system showing prior submission) and the appropriate Adjustment or Appeals Request form. Copy of claim, written explanation and pertinent documentation (follow up calls, electronic transmission reports) and CIGNA s Provider Payment Appeal Form. Consolidated currently does not accept electronic claims. They anticipate accepting them prior to the end of Copy of transmission log showing proof of clearing house receipt, copy of report showing health plan receipt and the appropriate Adjustment or Appeals Request Form. Great-West Healthcare (formerly One Health Plan) HMC- PPO/Northeast Healthcare (recently acquired by MultiPlan) Harvard Pilgrim Health Care 90 days 90 days from the original denial. 120 days 120 days from the original denial. 180 days 90 days from HPHC's original denial or payment date. Contact the Customer Service Center at Non COB-related claims: printout of patient accounts ledger. Denied Claims: Copy of EOP and HPHC Appeals form (see sample form and footnote below). COB-related claims: copy of EOB from primary insurer. Contact the Customer Service Center at WebMD: Unprocessed claim report (R059), Provider Daily Statistics Report (R022), Daily Acceptance Report (R026), File Detail Summary Report (RPT-04), Provider Claim Status (RPT-10) or Special Handling/Unprocessed Claim Report (RPT- 11) ProxyMed: Response Report Harvard University Group Health Program 180 days Contact provider relations rep: Jeanne Ramalho (617) Contact Provider Relations rep: Jeanne Ramalho (617) Direct Submission: Response Report Contact Provider Relations rep: Jeanne Ramalho (617) Note: Depending on the type of appeal, the following additional documentation may be required: operative notes, pathology reports, complete description of services rendered, etc. (revised 3/05)

9 Health Plan Claim Filing Limit Appeals Filing Limit Paper Claim Electronic Claims Healthcare VALUE Management Integrated Health Plan Medicaid- MassHealth 60 days It will vary by client. Call the number on back of card. 18 months 90 days from the original 90 days up to one year with waiver Medicare 60 days will accept up to 18 months denial. One year from the denial date 120 days from the denial date Submit copy of claim, written explanation and pertinent documentation (patient account screen shots) to: Division of Medical Assistance Final Deadline Appeals Unit 600 Washington Street Boston, MA Telephone review: Submit copy of claim, written explanation and pertinent documentation (patient account screen shots) to: NHIC Medicare B Appeals P.O. Box 1000 Hingham, MA Submit copy of claim, written explanation and pertinent documentation (patient account screen shots) to: Division of Medical Assistance Final Deadline Appeals Unit 600 Washington Street Boston, MA Telephone review: Submit copy of claim, written explanation and pertinent documentation (patient account screen shots) to: NHIC Medicare B Appeals P.O. Box 1000 Hingham, MA MultiPlan 60 days It will vary by client. Call the number on back of card. Neighborhood Health Plan 90 days 90 days Submit copy of claim, written explanation and pertinent documentation (patient account screen shots) to: Neighborhood Health Plan Appeals Department 253 Summer Street Boston, MA Submit copy of claim, written explanation and pertinent documentation (EDI acceptance report) to: Neighborhood Health Plan Appeals Department 253 Summer Street Boston, MA Note: Depending on the type of appeal, the following additional documentation may be required: operative notes, pathology reports, complete description of services rendered, etc. (revised 3/05)

10 Health Plan Claim Filing Limit Appeals Filing Limit Paper Claim Electronic Claims Network Health 90 days Within 60 days of initial denial (date of the EOB). Claims payment appeals should be sent to the following address along with a print screen of the patient activity or a billing ledger: Network Health Attn: Appeals Department P.O. Box Cambridge, MA Denied claims for codes 950 (no authorization) or 970 (timely filing) should be sent to: Submit a copy of Scrubber Report. Network Health Attn: Research and Resolution 432 Columbia Street, Suite 23 Cambridge, MA Pinnacle Health 60 days Not specified Private Health Care Systems 60 days 365 days TRICARE/Health Net Federal Services 365 days 90 days of the receipt of EOB. Contact provider relations rep: Kathy Vorse (781) Contact provider relations rep: Kathy Vorse (781) Tufts Health Plan 90 days Commercial- 120 days from date of EOB denial. Secure Horizons- 60 days from date of EOB denial. See attached policy. See attached policy. Note: Depending on the type of appeal, the following additional documentation may be required: operative notes, pathology reports, complete description of services rendered, etc. (revised 3/05)

11 Health Plan Claim Filing Limit Appeals Filing Limit Paper Claim Electronic Claims UniCare Commonwealth Indemnity 2 years 60 days from EOB United Healthcare 90 days 365 days from date of EOB Attach supporting documentation and submit to: Commonwealth Service Center PO Box 9075 Andover, MA Include copy of EOB showing original submission. If unavailable, provide screen shot of patient account showing date of prior submission. COB claims: include copy of EOB form primary insurer. Attach supporting documentation and submit to: Commonwealth Service Center PO Box 9075 Andover, MA Include copy of Acceptance (scrubber) Report showing that UHC or one of its affiliates received the claim. United Student Insurance 90 days 90 days from date of denial Appeals should be sent to the claims address on the EOB and should be accompanied by the UHC Reconsideration Form. All appeals should be in writing with supporting documentation attached. Send appeals to: Appeals should be sent to the claims address on the EOB and should be accompanied by the UHC Reconsideration Form. All appeals should be in writing with supporting documentation attached. Send appeals to: Student insurance Division PO Box Dallas, TX Student insurance Division PO Box Dallas, TX Note: Depending on the type of appeal, the following additional documentation may be required: operative notes, pathology reports, complete description of services rendered, etc. (revised 3/05)

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14 Thomas Cabral Director, Provider Relations June 13, 2003 ahealthcare Dear Participating Provider: Routing 307 Three Newton Executive Park 2223 Washington Street, Suite 200 Newton, MA Telephone ext We're making an important change to our provider payment appeals process as part of our focus on streamlining administrative policies and increasing provider satisfaction. Appeal Simplification Effective June 30, 2003, participating providers in the CIGNA HealthCare network can now direct first- and second-level appeal requests relating to CIGNA HealthCare managed care plans (which include our HMO, POS, Open Access and Network, Network POS and Network Open Access plans) to a single address: CIGNA HealthCare P.O. Box 5200 Scranton, PA This change is designed to help simplify the administration of appeals and facilitate improved responsiveness to requests to check on the status of an appeal. This policy is applicable to physicians, hospitals and other participating providers in the CIGNA HealthCare network. You may continue to contact CIGNA HealthCare Member Services to check the status of an appeal once it is received. Please note there are no changes to the payment appeals process for PPO plans. For your convenience, we have enclosed: A new provider payment appeal form that can be used instead of the former provider appeal letter. The form contains the required submission guidelines and the timeframes for the appeals process. A Quick Reference Guide detailing the provider payment appeals policy (enclosed for your background information). We hope you find this simplified appeal submission process beneficial and responsive to your needs. For additional copies of this information, please visit If you have questions, contact your CIGNA HealthCare representative. Thank you for your participation in the CIGNA HealthCare network. Sincerely, Thomas Cabral Director, Provider Relations Enclosure CIGNA HealthCare refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc.

15 REQUEST FOR PROVIDER PAYMENT APPEAL AHealthCare Please check one: Level-One Provider Payment Appeal (Must be submitted in writing within 180 calendar days of the date of the initial payment notice.)* Level-Two Provider Payment Appeal (Must be initiated within 60 calendar days of the date of the Level One appeal decision letter.)* *Subject to applicable laws and/or your provider agreement. All requests for a provider payment appeal should include: 1. A completed provider payment appeal form (below) initiating the appeal OR a letter of appeal requesting review and indicating the reason for the appeal. 2. A copy of the original claim and explanation of payment (EOP) or explanation of benefits (EOB), if applicable. 3. Supporting documentation for reconsideration. For provider appeals with a clinical component (such as denied inpatient days, or services denied for no prior authorization), additional documentation should include a narrative describing the situation, an operative report, and medical records as applicable. Provider Requesting appeal: Tax ID#: Provider of Denied Service: (If different) CIGNA HealthCare Member Name: Date of Birth CIGNA HealthCare Member ID#: Claim Number: Date(s) of Service: Procedure(s) or Type of Service(s): Diagnosis: Reason for Appeal: Denied Inpatient Days ** No Precertification/No Prior- Authorization** No Referral Untimely Filing of Claim Modifier/Code Review Fee Dispute Other (specify) Clinical documentation attached**: Yes No **Appeals of Denied Inpatient Days or claims denied for No Precertification or Prior Authorization must include complete medical records. Reason for Appeal/Supporting Information: Proud National Sponsor of the March of Dimes WalkAmerica the Walk that Saves Babies CIGNA HealthCare refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc

16 Preparer/Contact: Phone #: Please check the appropriate type of appeal below and mail this completed form and supporting documentation to: Managed Care appeal PPO appeal CIGNA HealthCare Mail to the address on the CIGNA P.O. Box 5200 HealthCare participant s ID card. Scranton, PA Please allow 45 days (or the time permitted by applicable law) for processing of your appeal and communication of the appeal decision. Please submit one appeal form per claim. Thank you.

17 Provider Appeal Process Effective June 2003 CIGNA HealthCare has streamlined its payment appeal process to help simplify the administration of appeals for your practice. Below are the requirements for the payment appeal process; changes* effective June 2003 are italicized. Provider Payment Appeal Process To initiate a first-level review of a payment or denial, please submit in writing within 180 calendar days of the date of the initial payment or denial notice the following information: A completed provider payment appeal form or a provider payment appeal letter indicating the reason for the appeal. A copy of the original claim and explanation of payment (EOP) or explanation of benefits (EOB), if applicable. Supporting documentation for reconsideration. For provider payment appeals with a clinical component (such as denied inpatient days, or services denied for no prior authorization), supporting documentation should include a narrative describing the situation, an operative report, and medical records as applicable. For managed care payment appeals, this information should be sent to: CIGNA HealthCare P.O. Box 5200 Scranton, PA For PPO payment appeals, this information should be sent to the address listed on the CIGNA HealthCare participant s ID card. If you are not satisfied with the resolution of the first-level review, you may submit the appeal to the second level of review within 60 calendar days of the date of the first-level review determination. This should also be sent to the appropriate address per the instructions above. If you wish to request an appeal, you must do so within the timeframes described above, or the last determination by CIGNA HealthCare regarding the issue will be binding (subject to applicable law or unless your provider agreement specifies differently). For additional copies of this information, visit our Web site at *Does not apply to providers in the following states: NJ, DE, MD, NM, PA, CA, OR, WA, and TX. Does not apply to government plans. CIGNA HealthCare refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc

18 Please allow 45 days (or the time permitted by applicable law) for processing of your appeal and communication of the appeal decision. Please submit one appeal form per claim. Thank you. CIGNA HealthCare refers to various operating subsidiaries of CIGNA Corporation. Products and services are provided by these subsidiaries and not by CIGNA Corporation. These subsidiaries include Connecticut General Life Insurance Company, CIGNA Vision Care, Inc., Tel-Drug, Inc. and its affiliates, CIGNA Behavioral Health, Inc., Intracorp, and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc

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21 PROVIDER CLAIM APPEAL FORM This form was developed to expedite the process of your appeal and should be used to submit provider claim appeals to Harvard Pilgrim Health Care. (Do not use this form for filing limit appeals.) Please complete all fields on the form, attach any pertinent supporting documentation and send the appeal to Harvard Pilgrim Health Care at the following address: Harvard Pilgrim Health Care P.O. Box Quincy, MA Telephone: Provider Name: Federal Tax ID Number: Contact Name: Contact Number: HPHC Provider ID Number: Provide the following information from your Explanation of Payment (EOP): Note: All claim appeals must be received within 180 days of the EOP date. Claim Number: Date of Service: Procedure Code: EX Code: Note any additional comments or explanation of issues below. Supporting Documentation for Provider Appeals When submitting an appeal, it is necessary to supply all supporting documentation for the issue being appealed. Each denial requires specific documentation to substantiate an appeal. Examples of such documentation may include copies of one or more of the following: Original Explanation of Payment (EOP) Surgical/operative notes Office visit notes Pathology reports Medical invoices (e.g., DME or pharmaceuticals) Medical record entries Letter of explanation describing the issue Provider Appeal - Form Rev 0602 PCT

22 Filing Limit Policy Claims Submission Guidelines Tufts Health Plan requires submission of claims within the contracted filing limit of 90 days for commercial claims and 60 days for Secure Horizons, Tufts Health Plan for Seniors claims from the date of service, the date of hospital discharge or, in the case of multiple insurers, the date of the primary insurer s explanation of benefits (EOB). In the case of multiple insurers, the EOB from the primary insurer must be submitted with the claim when Tufts Health Plan is the secondary payer. Initial Claims Submission Addresses The following addresses are for the initial submission of claims for Tufts Health Plan according to product: HMO or TMC POS, EPO or MCP PPO Tufts Health Plan HMO Tufts Health Plan POS Tufts Health Plan PPO P.O. Box 9163 P.O. Box 9171 P.O. Box 9185 Watertown, MA Watertown, MA Watertown, MA Secure Horizons Uniformed Services Family Health Plan P.O. Box 9183 P.O. Box 9203 Watertown, MA Waltham, MA Coordination of Benefits Tufts Health Plan follows the regulations by the Massachusetts Division of Insurance to determine which plan has primary obligation to provide benefits. Submit initial claim with Explanation of Benefits (EOB) from Primary Insurer to address above according to product. Claims submitted without an EOB will be denied. Tufts Health Plan Complement Plans must be submitted with the Medicare EOB. Claims submitted without an EOB will be denied. Note: The Tufts Health Plan filing limit policy does not apply to the Medicare Complement Plans. Motor vehicle accident related claims should be submitted with copy of PIP letter. Additional Information Visit our Web site, to check member eligibility, submit and check referral authorizations, submit preregistration requests or review claims status and general policy information. Providers may contact Tufts Health Plan s Provider Services Department (see the telephone numbers below) for direct inquiries or follow-up regarding claims status and payment issues, member eligibility, benefit coverage and copayments: Tufts Health Plan Provider Services Department (888) Tufts Health Plan PPO (800) Uniformed Services Family Health Plan (800) Secure Horizons Provider Services Department (800) For specific inquiries on submitting electronic claims, either directly to Tufts Health Plan or through a clearinghouse, contact our EDI Department by telephone at (888) , extension 4042 or by at EDI_Operations@tufts-health.com. Pre-addressed envelopes for mailing initial claims and chart labels identifying Tufts Health Plan members are available free of charge from Kelley Direct Solutions at (800) Please have your Tufts Health Plan provider number ready when ordering. Provider Support 9433 Updated January 28, 2003

23 UnitedHealthcare Request for Reconsideration Form Mail form to the address on the Explanation of Benefits (EOB) or the Provider Remittance Advice (PRA). PHYSICIAN HOSPITAL Other health care professional (Lab, DME, etc) Date Form Completed: First Submission of Request for Reconsideration Subsequent Submission of Request for Reconsideration ENROLLEE INFORMATION Commercial Enrollee Medicare Enrollee Medicaid Enrollee Enrollee ID: Enrollee Name: Last First MI Patient Name: Last First MI Control / Claim #: D.O.S. Billed Amount PHYSICIAN/HEALTH CARE PROFESSIONAL INFORMATION Tax Identification Number: Physician Name (as listed on PRA / EOB) : Last First MI and / or Facility/GroupName Contact Person: Phone Number: REASON FOR RECONSIDERATION 1. Previously denied / closed as Exceeds Filing Time (attach valid proof of timely filing, computer generated activity or print screen, EOB statement or letter from another insurance carrier which proves claims were filed timely) 2. Previously denied / closed for Additional Information (provide description and/or requested documents) 3. Previously denied / closed for Coordination of Benefits information (attach primary carrier s Explanation of Benefits) 4. Resubmission of a corrected claim (explain below) 5. Previously processed but contracted rate applied incorrectly resulting in over/underpayment (explain below) 6. Resubmission of Prior Notification Information (including notification information) 7. Resubmission of Bundled claim (including all supporting information) 8. Other (explain below) Comments: Required Attachments: Copy of Provider Remittance Advice (PRA) or EOB Claim form (with corrections if necessary) Other required attachments as listed above. 04/07/03 NO NEW CLAIMS SHOULD BE SUBMITTED WITH THIS FORM. SUBMIT A SEPARATE FORM FOR EACH CLAIM